When I saw the thread closed I figured things had gotten too heated! I read what had been posted and am glad to know everyone's remained civil, despite different opinions and life experiences. While I definitely have my own thoughts and feelings on how and where I want to give birth, I've found it interesting to hear other people's viewpoints.

While I admire your interest in birth and its policies, 45 interviews over the course of 5 years is, I'm afraid, almost no data. While you have conducted interviews, I have delivered babies (between 40 and 45); more importantly, in order to gain my full medical licensure (as i have done) I have to be both theoretically and practically grounded in obstetrics. Therefore you're quite right in saying its not my area of expertise and I am not pretending to be an obstetrician- I'm a general surgeon who hopes to specialize in heart transplants. But I am pretending basic competency in obstetrics.

There are about 4.3 million live births annually in the US; approximately 0.75% occur out-of-hospital (including planned and unplanned home births, and freestanding birth center births). Again, interviewing 45 women over five years would represent 0.00002% of all births in the US. That is hardly an adequate sample size from which to draw any conclusions.

More importantly, your data is likely to be invalid in addition to being underpowered. Interviews are subject to many biases. The first bias is recall bias-- someone is much more likely to recall something that impacted them negatively and to speak of it in greater detail than someone who had a neutral experience. The second is sampling bias: women seeking alternative obstetric care are much more likely to have been dissatisfied, or to have had genuinely poor care, than average. When your research subjects describe their experiences to you, they are unlikely to represent the experience of all US mothers. Lastly, the gravest problem of all is that you can very, very rarely corroborate the account of an interview subject. You as the interviewer are a passive recorder. You have no idea what really happened; you simply must accept your subject's account at face value. That doesn't mean your ladies are lying, but it does mean that you'll never know.

On the other hand, my experience and the knowledge which I am routinely examined upon (and required to put into practice) comes from the fairly rigorous study of the 99.25% of the 4.3m American births that occur in a hospital annually. I have absolutely no doubt that the standard of care is not evenly applied. There are doubtless pockets of the US or individual hospitals that need to catch up. There is a great deal of pressure, both inward and outward, for the medical system to examine itself and improve its practices. When you say childbirth care is 'evidence-based,' who do you think is collecting, analyzing and validating the evidence?

Take everyone's favorite bogeyman, the enema. In the past it was hypothesized that the mother pooping in labor would contaminate the perineum, thus infecting the baby and causing a problem similar to meconium aspiration syndrome, only milder. A few doctors started to say, hang on, this doesn't really seem to be a problem. A study was conducted where half of laboring women were administered routine intrapartum enemas, half weren't. No difference in the infection rate amongst babies, and the practice was discarded back in the 70s.

So I am all for the critical examination of any aspect of medical science or medical practice. It's the only way progress is made. The question, for example, as to whether epidural analgesia stalls out labor and increases the csection rate is a very legitimate, thoughtful question. Definitely worth studying. Luckily it has been exhaustively and rigorously studied, with good-quality evidence that it does not. *This* is the way scientific progress is made. A hypothesis can absolutely be generated from weak-quality data like interviews, but no evidence of sufficient strength to actually affect a practice change can be drawn from it. That's derogatorily called 'anec-data.'

Finally: it's a funny belief I've encountered that doctors must have never seen or managed a normal, uncomplicated childbirth where no interventions were warranted. Nothing could possibly be farther from the truth. Personally I did my obstetrics rotation at one of the highest-acuity, highest-volume hospitals in the US. Nearly everyone had a severe medical or obstetric problem-- I saw three-vessel vasa plegia with triplets, a mother with primary pulmonary hypertension who died after five days on a permanent heart-lung machine as the physiology of childbirth completely destroyed her heart, you name it. All the ultra-rare, ultra-bad problems. Then I did the last half on a Native American reservation in the Southwest, where no obstetrician or anesthesiologist was available. Every childbirth was unmediated and vaginal because that's all there was (anyone higher risk was transferred to a nearby city). In both settings all of the nice, comfy options were available, as they were to me in my own fancy hospital when i gave birth. The baby I most recently delivered, in the ER a few months ago, almost fell out of his mom after just two pushes; I barely had time to get her pants off before the baby as in my arms. and this is absolutely what you need to be a competent birth provider: you need to have seen and managed the normal and the abnormal, otherwise you'll never even recognize the bad even when it's staring you in the face.